Provider Network Management Solutions Help Boost the Access to Care


A healthcare provider network is a list of doctors, hospitals, and other providers that an insurance coverage plan associates with to provide medical care to members. Providers who fall into a health plan’s network are called in-network providers and those that don’t are called out-of-network providers. In addition to clinical doctors, a health plan’s in-network providers could also include nurses, therapists, and also home care professionals.




The workflow surrounding the growth and day-to-day healthcare provider network management is no small feat. There is an elaborate series of steps to onboard a provider into a network, through a process called credentialing. This is followed by regular, day-to-day activities like data management, analytics, contracting, credentialing pricing, maintenance, configuration, and so forth. Needless to say, it is a complex bureaucratic process that requires dedicated administrative solutions.


The push to improve efficiency in managing provider networks has many healthcare software provider companies racing to develop innovative networking management solutions. One of the cornerstones of such solutions is the function to harness data for optimizing operations. Every industry from banking, tourism, manufacturing, construction to retail and telecommunications generates data from day-to-day operations. This holds important insights to help the management make informed decisions.


Solutions to optimize healthcare provider management help improve care delivery over the long term by assessing operational data from insurance payers to identify high-risk providers. Based on this insight, the health plans might be adjusted to ensure adequate coverage for members. Additionally, a digital platform for healthcare network management also helps insurance companies optimize the process of developing and servicing the network, offering the maneuverability to apply newer policies to adapt to changes in the industry. Some of those changes include new products, payment approaches, and models of delivering care.


The current model of care pays providers on the basis of the number of services provided. It is called the fee-for-service model. But growing costs of healthcare have pushed people and policymakers to call for a change from the fee-for-service model to a value-based reimbursements model. This call had been around for years but grew louder and louder in the wake of the Covid-19 pandemic. As policymakers work to enable a shift over to a value-based model, solutions for network management in healthcare have shown the potential to help payers implement and govern the value-driven model. 


In addition to helping the transition over to a value-driven model, an effective provider data management solution also assists in improving the access to care. These solutions help improve the efficiency and productivity of management activity, thereby helping the network expand and accommodate a greater number of services. Furthermore, such platforms also help facilitate data analytics to help payers in many ways like the accurate prediction of risks, better negotiating room, and cost-effectiveness.


Increasing digitization across the healthcare industry is bound to bring about changes. One of the biggest changes that are right around the corner is telehealth. As payers and policymakers struggle to develop regulatory frameworks to include telehealth into insurance plans, effective network management in healthcare would be a good position to smoothen the entire process.     

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